Table 3.
Identified enablers and barriers coded according to clinical microsystems success characteristics and representative verbatim quotes
| Success characteristics13 15 | Representative quotes | |
| Enablers | Barriers | |
| 1. Leadership: the role of leaders is to balance setting and reaching collective goals, and to empower individual autonomy and accountability, through building knowledge, respectful action, reviewing and reflecting. | “You do have to have, as an absolute minimum, you have to have one person who has both the vision and the position to be able to make things change. Ok"? (GP, RRMA 5) | “…having some degree of buy in from the partners I think was crucial, and times when there wasn’t that buy in nothing moved”. (GP, RRMA 1) |
| 2. Organisational support: the larger organisation looks for ways to support the work of the microsystem and coordinate the hand-offs between microsystems. | “I think being involved in more than one wave of the APCC is terrific, because one wave [Interviewer: So your comment is not one wave, go further…]…Yeah I love it, I miss it and I always learn an enormous amount…. Even being part of their, you know, communication…. There’s email communication between practices… so hopefully they’ll keep getting funding and keep doing different ideas”. (GP, RRMA 1) | “You know a lot of doctors are a bit suspicious, thinking, even they think the APCC is a government plan to get to know their numbers… and I was amazed when I spoke and I heard this, you know, they were really suspicious. So, I think that’s one barrier they have got to get through”. (GP, RRMA 1) |
| 3. Staff focus: there is selective hiring of the right kind of people. The orientation process is designed to fully integrate new staff into culture and work roles. Expectations of staff are high regarding performance, continuing education, professional growth and networking. | “Making sure that all the staff are trained in what is expected of them: understand their role; understand their limitations, understand the reporting procedures; have an open door policy; … and make sure people, make sure staff aren’t frightened to say something, because …they’re frightened that they’ll get a negative response whatever: an open door policy”. (PM, RRMA 2) | “The practice will pay for certain professional development things. Whereas I know some general practices don’t have that…that whoever’s the boss doesn’t want to pay for anything”. (PN, RRMA 1) |
| 4. Education and training: all clinical microsystems have responsibility for the ongoing education and training of staff and for aligning roles with training competencies. Academic clinical microsystems have the additional responsibility of training students. | “I would say, what general practice is doing at a training level, in terms of interns and medical students and registrars. That… starting with that cohort, you can actually influence how they will end up practicing as GPs and that might be something that you start back at this level that it actually flows through over a period of time”. (PM, RRMA 4) | “I think there’s an ongoing pressure from external organisations to keep providing services, because they’re short of examiners, short of teachers, short of people to run intern placements, and so there’s a continuous drive to keep us doing those, those external activities. And it comes down in the end to the doctors making a lifestyle choice, and how much time they want to prioritise their general practice and their other interests”. (GP, RRMA 1) |
| 5. Interdependence: the interaction of staff is characterised by trust, collaboration, willingness to help each other, appreciation of complementary roles, respect and recognition that all contribute individually to a shared purpose. | “Culture… is hard to replicate. I think we have a good culture. I think people are engaged; they’re happy. And it’s not all perfect, don’t get me wrong, you know, you do have issues, but I think people genuinely feel that they make a difference and they are allowed to make a difference, and they have input. So, something all our staff have is input, come up with an idea, we’ll look at it”. (PM, RRMA 5) | “My experience from going out to conferences and networking with other nurses in other practices is that the nurses don’t have a lot of freedom from the doctors. The doctors like to have a very tight rein on what’s going on in their practice and the nurses nearly of just do those clinical tasks of supporting the doctor, you know? … And don’t really get to use their skills that they have”. (PN, RRMA 5) |
| 6. Patient focus: the primary concern is to meet all patient needs—caring, listening, educating and responding to special requests, innovating to meet patient needs and smooth service flow. | “When I set the practice up, I had certain aims: one was to have a high quality practice. One where I and my staff liked to work and one where my patients felt comfortable to come and felt better when they left than when they arrived. So, you know, if you’re going to sit in a stinking waiting room and everyone’s loud and noisy, you leave the surgery feeling worse than when you arrived”. (GP, RRMA 4) | “I think that the (macro)system is designed to reward individual, quick medicine, ah dealing with a small number of problems, and … doesn’t support good team based chronic disease management; a lot of the stuff that our nurses do…there’s no item number for that. It frees up our time and it gives better care to our patients, but it’s not financially rewarding”. (GP, RRMA 4) |
| 7. Community and market focus: the microsystem is a resource for the community; the community is a resource to the microsystem; the microsystem establishes excellent and innovative relationships with the community. | “We have a particular stable patient base, if you like, we know our patients very well… we work as a family and the community is very much a community and the doctors have values about looking after that community…” (PM, RRMA 4) | “Doctors…are not in it to make money necessarily; they are in it to care for the community. So, there’s a different approach to the whole billing side of things…that may not work for some practices”. (PM, RRMA 4) |
| 8. Performance results: performance focuses on patient outcomes, avoidable costs, streamlining delivery, using data feedback, promoting positive competition and frank discussions about performance. | “You have to be obsessive and say ‘I have to do this…’ ‘we’re trying to get HbA1c better’, ‘we want to get the blood pressure better’…. And so, constantly chasing the target”. (GP, RRMA 1) | ‘I think once all the systems are set up, it’s all easy…It’s just having the time to set them up”. (PM, RRMA 1) |
| 9. Process improvement: an atmosphere for learning and design is supported by the continuous monitoring of care, use of benchmarking, frequent tests of change and a staff that has been empowered to innovate. | “Even any little improvement is good, you know, so I think that’s how to start practice off, … small changes monthly are, are really good”. (GP, RRMA 1) | “If you try to do five things, they’ll all flop, and when they all flop people are disenchanted and then you’re trying to and they say, ‘oh but we tried that last time’”. (PM, RRMA 1) |
| 10. Information and information technology: information is THE connector—staff to patients, staff to staff, needs with actions to meet needs. Technology facilitates effective communication and multiple formal and informal channels are used to keep everyone informed all the time, listen to everyone’s ideas and ensure that everyone is connected on important topics. | “We now get information on the percentage of medications printed in the last 6 months. You know, the number of diagnoses, even though our patient load is going up we’re trying to get the number of diagnoses down. So everything there is relevant, and we’ve also marked everything there as confidential, so that when we do upload an electronic health history, only relevant stuff, is there”. (GP, RRMA 1) | “…With the e-health, it does take a lot of time. Even the registration, we found that, you know quite difficult and to get to the state of uploading histories is time consuming: getting rid of old diagnoses; making sure medications are in date, we’ve done a lot of work on that, you know, making sure their over-the-counter medicine is up to date”. (GP, RRMA 1) |
GP, general practitioner; PM, practice manager; PN, practice nurse; RRMA, Rural, Remote and Metropolitan Areas.